title: Outcomes of patients with head-and-neck cancer of unknown primary origin treated with intensity-modulated radiotherapy.
abstract: OBJECTIVE
  To analyze survival, failure patterns, and toxicity in patients with head-and-neck carcinoma of unknown primary origin (HNCUP) treated with intensity-modulated radiotherapy (IMRT).
  
  
  METHODS
  Records from 27 patients with HNCUP treated during the period 2002-2008 with IMRT were reviewed retrospectively. Nodal staging ranged from N1 to N3. The mean preoperative dose to gross or suspected disease, Waldeyer's ring, and uninvolved bilateral cervical nodes was 59.4, 53.5, and 51.0 Gy, respectively. Sixteen patients underwent neck dissection after radiation and 4 patients before radiation. Eight patients with advanced nodal disease (N2b-c, N3) or extracapsular extension received chemotherapy.
  
  
  RESULTS
  With a median follow-up of 41.9 months (range, 25.3-93.9 months) for non deceased patients, the 5-year actuarial overall survival, disease-free survival, and nodal control rates were 70.9%, 85.2%, and 88.5%, respectively. Actuarial disease-free survival rates for N1, N2, and N3 disease were 100%, 94.1%, and 50.0%, respectively, at 5 years. When stratified by non advanced (N1, N2a nodal disease without extracapsular spread) vs. advanced nodal disease (N2b, N2c, N3), the 5-year actuarial disease-free survival rate for the non advanced nodal disease group was 100%, whereas for the advanced nodal disease group it was significantly lower at 66.7% (p = 0.017). Three nodal recurrences were observed: in 1 patient with bulky N2b disease and 2 in patients with N3 disease. No nodal failures occurred in patients with N1 or N2a disease who received only radiation and surgery.
  
  
  CONCLUSIONS
  Definitive IMRT to 50-56 Gy followed by neck dissection results in excellent nodal control and overall and disease-free survival, with acceptable toxicity for patients with T0N1 or non bulky T0N2a disease without extracapsular spread. Patients with extracapsular spread, advanced N2 disease, or N3 disease may benefit from concurrent chemotherapy, targeted therapeutic agents, or accelerated radiation regimens in addition to surgery.
authors.affiliation: Department of Radiation Oncology, University of Virginia, Charlottesville, VA 22908, USA.
authors.forename: Asal
authors.initials: A
authors.lastname: Shoushtari
authors.forename: Drew
authors.initials: D
authors.lastname: Saylor
authors.forename: Kara-Lynne
authors.initials: KL
authors.lastname: Kerr
authors.forename: Ke
authors.initials: K
authors.lastname: Sheng
authors.forename: Christopher
authors.initials: C
authors.lastname: Thomas
authors.forename: Mark
authors.initials: M
authors.lastname: Jameson
authors.forename: James
authors.initials: J
authors.lastname: Reibel
authors.forename: David
authors.initials: D
authors.lastname: Shonka
authors.forename: Paul
authors.initials: P
authors.lastname: Levine
authors.forename: Paul
authors.initials: P
authors.lastname: Read
mesh_terms: D000368:Aged; D018572:Disease-Free Survival; D005260:Female; D006258:Head and Neck Neoplasms / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy*; D006801:Humans; D008197:Lymph Node Excision; D008198:Lymph Nodes / Q000473:pathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D009382:Neoplasms, Unknown Primary / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy*; D011879:Radiotherapy Dosage; D050397:Radiotherapy, Intensity-Modulated; D012189:Retrospective Studies; D016896:Treatment Outcome